Getting Fully Aquainted with Bipolar Disorder

Stigma and a lack of understanding has led to a 10-year gap in treatment.

Posted Jul 09, 2018

Recently, we’ve been hearing more in the news about celebrities who have openly shared their bipolar stories and have encouraged others to recognize bipolar in their own lives. And tragically, we’ve also heard about individuals allegedly with bipolar disorder who have died by suicide or committed acts of violence against others. From a society perspective, bipolar disorder is slowly coming out of the woodwork, and people are starting to ask more questions about this often misunderstood mental illness. Heightened awareness is a good thing, of course. But a profound stigma against treatment still exists, along with a general lack of understanding about bipolar disorder and what can be done about it.

The gap in knowledge about bipolar is exceeded only by the length of time people with the illness begin showing symptoms and when they’re actually treated appropriately. Drancourt et. al (2012) showed that, on mean average, patients will have waited nearly 10 years from their first bipolar mood episode to the time they receive a mood stabilizing medication specifically for bipolar disorder. Another study showed about two-thirds of bipolar patients are misdiagnosed and treated as having other psychiatric disorders (mostly major depression), while those patients had consulted a mean average of nearly four clinicians before receiving appropriate care (Hirschfeld, Lewis, & Vornik, 2003). Because of this 10-year gap in treatment, we have a whole population of underlying bipolar disorder presenting as relational dysfunction, substance abuse, unipolar depression, attention deficits, self-harm, personality disorders, domestic violence, workplace conflicts, and many other common presentations to outpatient therapy.

But the biggest problem with unidentified and untreated bipolar disorder is suicide, which is at least 20 times higher in bipolar patients compared to the general population (Berk, Scott, Macmillan, Callaly and Christensen, 2013).  Perhaps even more striking, The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association [APA], 2013) states that “bipolar disorder may account for one-quarter of all completed suicides” (p. 131). While many people with undetected bipolar matriculate—then languish—through an often cumbersome mental health system, their condition worsens, threatening their own life along with the well-being of every concerned person around them. 

With a prevalence up to 5% of the population (Ketter, 2010), a unified method to effectively recognize and comprehensively treat this chronic and deadly mental illness is critical. It’s certainly time to fully understand what bipolar is, how to better recognize and openly discuss it, and treat it in a unified manner with active support around the person suffering from uncontrollable mood swings.

It’s time to get fully acquainted with bipolar disorder.

Bipolar disorder, sometimes referred to as manic-depression, is a genetically-based psychiatric disorder, which involves poorly regulated changes in brain chemistry that creates extreme mood swings. Episodes of mania or hypomania can include euphoric and expansive mood; or dysphoric mood, which is marked by high levels of irritability and agitation. These episodes can also include grandiose self-image, decreased need for sleep, rapid thoughts, pressured speech, distractability, increased energy and creative desires, and severe impulsivity that leads to high-risk behaviors. In depressive episodes, the mood becomes severely reduced, dark and demoralizing. Manic, hypomanic and depressive episodes can last from several days to several weeks. In the most severe instances of bipolar, psychotic features including hallucinations or delusions may be present during extreme mood events.

The causes of bipolar can be classified as either predispositional or catalytic. First, a person needs the predisposition to bipolar for the true pattern to eventually emerge during the lifespan, which means what is coded in the person’s DNA essentially sets the foundation for eventual symptoms. The strongest and most consistent causal factor for bipolar disorder is genetic (APA, 2013). Catalytic causes bring out those symptoms. Some common catalysts involve hormonal changes, such as in puberty, or in women during or after childbirth, known as peripartum bipolar onset. Drug and alcohol abuse can also trigger underlying bipolar symptoms. The average age of onset is late adolescence to early adulthood. Although as we’ve seen above, accurate recognition and diagnosis may not occur until several years into adult life.

Bipolar patients and their families often struggle to accept the disorder out of shame, which is born out of stigma. Knowing that bipolar is genetic in its foundations, with natural internal and external catalysts driving symptom emergence, people can appreciate that having bipolar is nobody’s fault. There really is no one to blame, and no reason to feel ashamed when bipolar becomes a part of a family’s life story.

Yet, many different fears can hold people back from seeking proper treatment. These include concerns about medications and difficulty accepting a lifelong mental illness. Many people with bipolar often fear giving up the great feelings that accompany a manic or hypomanic episode. Nobody wants to be told that what makes them feel terrific and supercharged is actually part of a disorder that should be taken away. As a result, the defense of denial is an expected aspect of bipolar disorder. It’s especially important for people with bipolar to feel in control of the energetic and hypercreative parts of mania as an offset to the desperate, hopeless feelings of their depressive episodes.

And family members can possess fears, and at times, denial of bipolar in their lives. For example, parents can worry more about their children being “labeled for life” than how the disorder can destroy their children's life goals. Or spouses of people with bipolar may initially view it as simply an excuse for their “bad behavior," as their relationships fall apart from the weight of every destructive behavior.

There are many roadblocks along the path to success with bipolar treatment. But a combination of thorough assessment, education, and treatment centered around the medical stabilization of bipolar swings is useful in addressing all pertinent fears for patients and families, while engaging these important members into a collaborative, lifelong care plan. Reducing fear in all participants is key to remaining connected to treatment while building hope that stabilization will ultimately improve the quality of life for bipolar patients and their families.

References

American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington VA: American Psychiatric Publishing.

Berk, M., Scott, J., Macmillan, I., Callaly, T. & Christensen, H.M. (2013). The need for specialist services for serious and recurrent mood disorders. Australian & New Zealand Journal of Psychiatry, 47 (9), 815-818.

Drancourt, N., Etain, B., Lajnef, M., Henry, C., Raust, A., Cochet. B., et al. (2012). Duration of untreated bipolar disorder: Missed opportunities on the long road to optimal treatment. Acta Psychiatrica Scandinavica, 127(2), 136-144.

Hirschfeld R.M., Lewis, L., Vornik, L.A. (2003). Perceptions and impact of bipolar disorder: How far have we really come? Results of the National Depressive and Manic-Depressive Association 200 survey of individuals with bipolar disorder. Journal of Clinical Psychiatry, 64(2). 161-174.

Ketter, T.A., (2010). Diagnostic features, prevalence, and impact of bipolar disorder. Journal of Clinical Psychiatry, 71. e14.